Danger Zones of the Gluteal Anatomy: Improving the Safety Profile of the Gluteal Fat Grafting.

INTRODUCTION: Knowledge of the vascular anatomy is critical to performing safe gluteal surgery. To date, only the course of the main blood vessels within the muscles has been outlined. These findings are based on MRI and CTA images that do not conform to a topographically standardized and normalized probability distribution. OBJECTIVES: The aim of this study was to develop a three-dimensional mapping of the gluteal zones of high vascular density in relation to anatomical landmarks. MATERIALS AND METHODS: This single-center retrospective cohort analysis comprised all consecutive patients who underwent cone-beam computed tomography (CBCT) scans between January 2016 and October 2021. The location of blood vessels in the gluteal region was allometrically normalized in relation to anatomical landmarks. Moreover, the caliber and area of the blood vessels were assessed. RESULTS: CBCT scans of 32 patients with an average age of 64 ± 12 years (range 34-87 years) were included. Fifty-three percent were female. The median [IQR] caliber of the intramuscular gluteal vessels was 1.47 [1.15-1.88] mm, significantly greater than that of the subcutaneous vessels 1.09 [0.72-1.44] mm (p < 0.001). Vascular density was higher intramuscularly, as 4.5% of the area of the muscle was occupied by blood vessels, as opposed to 0.3% in the adipose tissue. CONCLUSION: The analysis of the CBCT scans showed a higher vascular density and larger vessels intramuscularly. We, therefore, recommend the injection of autologous fat merely to the subcutaneous plane. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic Implications of Bilateral Profunda Artery Perforator Flaps on Thigh and Buttock Proportions.

BACKGROUND: The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated. METHODS: A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey. RESULTS: The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour. CONCLUSION: PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.

An atypical inferior gluteal artery passing through the piriformis muscle.

PURPOSE: In this article, we report a case of an atypical inferior gluteal artery that passed through the piriformis muscle when it emerged from the pelvic cavity in an elderly Japanese female cadaver. We speculate that this atypical artery could be entrapped and compressed by the piriformis muscle and may therefore be associated with piriformis syndrome; however, the anatomical characteristics of such an atypical artery have not been previously reported. To assess this potential association, the atypical inferior gluteal artery was anatomically examined. METHODS: The cadaver examined in this report was a 97-year-old Japanese female who was donated to The Nippon Dental University for use in medical education and research. The atypical inferior gluteal artery and surrounding structures in half of the pelvis were examined macroscopically. RESULTS: The atypical inferior gluteal artery arose from the common arterial trunk, formed by itself and the superior gluteal artery, passed through the superior proximal part of the piriformis muscle, and left the pelvic cavity. It supplies branches to the lower half of the gluteus maximus and proximal part of the long head of the biceps femoris muscle. The piriformis muscle originates from the 2nd to 4th sacral vertebrae and attaches to the greater trochanter via a single short tendon. CONCLUSION: According to our findings, when the atypical inferior gluteal artery is entrapped and compressed, ischemic signs and symptoms may emerge in the lower buttocks and proximal posterior thigh. These results provide a new perspective for the diagnosis and treatment of piriformis syndrome.

Using high-resolution imaging to study the impact of the Kalogon wheelchair cushion on blood flow in the gluteal area.

AIM OF THE STUDY: This study investigated how the air-bladder offloading mode of the Orbiter by Kalogon wheelchair cushion (Orbiter) affected blood flow in the gluteal region of non-disabled subjects. The hypothesis was that the cushion's offloading mode would improve blood flow, resulting in reduced reactive hyperemia when compared to the static setting, or Loaded Control (LC). Furthermore, the study proposed a technique using a high-resolution image laser speckle contrast system to measure blood flow in the gluteal area. METHODS: Two procedures were carried out, one with the participant sitting on a cushion in LC, and the second, the cushion was set to offloading mode. Blood flow was measured through data imaging after each procedure. Three trials were performed, starting and ending in different cushion bladders. Customized algorithms were used to select regions of interest on the images for calculations. The Wilcoxon Signed-Rank Test was conducted to compare the offloads and loaded control values of each region of interest. Results were considered significant at α = 0.05. RESULTS: Ten healthy, non-disabled adults participated in the study, seven females and three males. There were no significant differences among the participants. However, results showed that seven subjects tended to decrease reactive hyperemia in the offload sequence of trial when the last two bladders offloaded were the sacrum followed by the right ischial tuberosity. CONCLUSIONS: The high-resolution imager showed that the Orbiter Offloads helped reduce reactive hyperemia in seven subjects, potentially improving blood flow. More research is necessary to comprehend the mechanisms of these effects fully.

Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection.

BACKGROUND: The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. OBJECTIVES: The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. METHODS: A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. RESULTS: The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9 kg/m2 (range, 19.3-37.4 kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. CONCLUSIONS: Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.

Near-total gluteal defect reconstruction with bilateral delayed giant lumbar artery perforator flaps: A case report.

The reconstruction of the near-total or total gluteal defects is challenging. Reconstructive options were restricted when the gluteal flaps were sacrificed. The lumbar artery perforator flap (LAPF) has been recently popularized as an alternative option for sacral and gluteal pressure ulcers. Extension of flap size may be needed in extensive defects. We aim to use the delay phenomenon to increase lumbar artery perforator flap territory to reconstruct near total gluteal defect. A 36-year-old woman was referred to our clinic with defect sizes of 23 × 23 cm and 25 × 17 cm for the right and left gluteal regions. She had a history of multiple surgeries for her paraplegia-related sacrogluteal pressure sores. The reconstruction was started on the left side with delaying incisions to the flap borders. Seven days later, the left gluteal defect was reconstructed with 27 × 19 cm LAPF based on a second lumbar artery perforator. At the same session, the delaying incision was performed to the borders of the right LAPF. On day 14, the right gluteal defect was closed with a 25 × 25 cm-sized right LAPF. No flap loss and early complications were seen. The patient was discharged without complication after 10 days after the last operation. The patient was followed up for 1 year. A right ischial pressure ulcer due to wheelchair use was encountered, which was managed with conservative wound care in the 8th month. Giant-sized lumbar artery perforator flaps may be obtained by delay phenomenon to reconstruct near-total or total gluteal pressure sores.

Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy.

ABSTRACT: Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.

Comparison of Lumbar Artery and Superior Gluteal Artery Perforator Flaps for Breast Reconstruction: Multislice CT-Based Anatomical Study.

BACKGROUND: Although the deep inferior epigastric artery perforator flap is the criterion standard for autologous breast reconstruction, lumbar artery perforator (LAP) and superior gluteal artery perforator (SGAP) flaps are recent trends as alternatives. The purpose of our study was to clarify differences of these flaps based on multislice CT findings of the same patient. METHODS: Retrospective study was conducted on 58 patients who underwent preoperative contrast-enhanced multislice CT for breast reconstruction using deep inferior epigastric artery perforator. Of these, 32 patients' data were evaluated excluding 26 patients' data either for the lumbar or gluteal fat being outside the imaging range or for nondepiction of the vascular pedicle origin of LAP or SGAP flap. Vascular pedicle diameter, pedicle length, and subcutaneous fat thickness were measured for LAP and SGAP flaps. RESULTS: The vascular pedicle diameter, pedicle length, and fat thickness were 2.1 (SD, 0.3) mm, 3.4 (SD, 0.4) cm, and 4.9 (SD, 1.0) cm, respectively, for LAP flaps; and 1.7 (SD, 0.2) mm, 5.6 (SD, 1.1) cm, and 2.7 (SD, 0.7) cm, respectively, for SGAP flaps. CONCLUSIONS: The LAP flaps had thicker subcutaneous fat and a larger vascular pedicle diameter, whereas the SGAP flaps had a longer vascular pedicle. As donor material for breast reconstruction, the LAP flap is indicated for cases where absolute volume is needed; otherwise, the SGAP flap is more advantageous as it facilitates vascular anastomosis with its longer vascular pedicle.

A Single Superior Gluteal Artery Perforator Flap in Reconstruction of Large Midline Sacral Defects: A Method for Practical Harvest and Safe Closure.

BACKGROUND: Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. METHODS: Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. RESULTS: There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. CONCLUSION: Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.

Sensate superior gluteal artery perforator flap for reconstruction of sacrococcygeal large wound dehiscence: A case report and literature review.

The superior gluteal artery perforator (SGAP) flap is an option for the reconstruction of deep sacral defects. Since a conventional SGAP flap is not neurotized, covered ulcers have a risk of recurrence, especially when patients cannot ambulate by themselves. In ambulatory patients, the sensory presentation of reconstructed tissue assures its protection. Purpose of this report is to present a case of the use of a sensate SGAP flap for reconstruction of a sacrococcygeal large wound dehiscence in a patient and review of literature for sensate reconstruction of sacral defects. A 72-year old woman with a sacrococcygeal large wound dehiscence measuring 12 cm in length, 9.5 cm in width and 5 cm in depth was treated. The defect was caused by a wound dehiscence after abdomino-perineal resection for rectal cancer. A unilateral SGAP flap measuring 16 × 7 cm length and 5 cm width was designed in the right buttock and the cranial border of the flap was lined near the iliac crest. An SGAP flap was elevated including the superior cluneal nerve (SCN), turned clockwise 70°, and inset to the defect. The defect remained in the deep caudal part a parasacral adiposal flap measuring 7 × 10 cm was harvested from the contralateral side and filled the defect. The postoperative course was uneventful without any complication. Sensation was observed immediately after surgery. Postoperative Semmes-Weinstein monofilament test showed 3.22 at 9 months postoperatively. There was no recurrence during follow-up of 20 months. The sensate SGAP flap may be elevated with SCN and be considered for reconstructions of deep sacral defect.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement.

BACKGROUND: Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. OBJECTIVES: This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. METHODS: Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. RESULTS: A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. CONCLUSIONS: Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Gluteal Blood Flow Monitoring in Endovascular Aneurysm Repair With Internal Iliac Artery Embolization.

BACKGROUND: When an internal iliac artery (IIA) has to be embolized during endovascular aneurysm repair (EVAR), buttock claudication sometimes poses problems. However, there is no established method to evaluate intraoperative blood flow to the gluteal muscles.Methods and Results:Gluteal regional oxygen saturation (rSO2) was monitored using near-infrared spectroscopy (NIRS) during surgery, and changes in rSO2were compared with treatment results. Twenty-seven patients who underwent EVAR and IIA embolization at our institution between April 2019 and May 2020 were included in this study. The association between intraoperative changes in rSO2and postoperative incidence of buttock claudication was analyzed. Furthermore, the presence or absence of communication between the superior and inferior gluteal arteries and the intraoperative changes in rSO2were compared to ascertain whether rSO2reflects blood flow change. Postoperative buttock claudication occurred in 4 of 19 patients (21%) with unilateral occlusion of IIA and in 4 of 8 patients (50%) with bilateral occlusion of IIAs. rSO2was found to decrease significantly further in patients with buttock claudication than in patients without buttock claudication (-15±12% vs. -4±16%, P<0.05). In addition, rSO2was predominantly lower in patients without the communication between the superior and inferior gluteal arteries than in those with the communication. CONCLUSIONS: Gluteal rSO2is useful as an indicator of intraoperative gluteal blood flow.

Extension of Iliac Branch Device Repair Into the Superior Gluteal Artery Is a Safe and Effective Maneuver.

BACKGROUND: In some cases of complex aortoiliac endovascular repair, the hypogastric landing zone is suboptimal or even insufficient. This study aimed at the technical feasibility and at the outcome of iliac branch device (IBD) deployment with extension of the IBD into the superior gluteal artery (SGA). MATERIALS AND METHODS: This study involves a retrospective analysis of a prospectively maintained single-center cohort of patients with implantation of IBD for aortoiliac and postdissection aneurysms. The IBD cohort with landing zones in the hypogastric main trunk (IIA IBD) was compared with the IBD cohort with landing zones in the SGA (SGA IBD). The main outcome parameters were primary technical success, patency of the hypogastric branch, and freedom from IBD-specific secondary interventions within 30 days. Other outcomes of interest were long-term patency and freedom from buttock claudication, as well as the incidence of endoleaks. Group comparisons were made by univariate significance tests, and freedom from reintervention was analyzed with the Kaplan-Meier-method. RESULTS: From January 2015 to October 2017, a total of 46 IBDs were implanted in 40 patients (39 male; mean age, 71.9 ± 9.1 years). Nineteen of 46 (41.3%) IBDs were extended with at least one bridging stent graft into the SGA because of aneurysmal or short internal iliac artery (IIA). Technical success was achieved in 97.8% (96.3% for IIA IBD vs. 100% for SGA IBD, P = 0.163), and the primary ipsilateral limb patency rate was 100% within 30 days after the procedure. During a mean follow-up period of 19.8 ± 10.0 months (24.7 ± 10.8 for IIA IBD vs. 25.1 ± 9.8 for SGA IBD, P = 0.461), 11.1% IBDs in the IIA IBD group and 15.8% IBDs in the SGA IBD group needed secondary interventions (P = 0.33). Follow-up revealed no patients suffering from persistent buttock claudication or erectile dysfunction. One patient in the SGA IBD group died at late follow-up from a non-aneurysm-related cause. CONCLUSIONS: Extension of IBD into the SGA is a technically feasible and safe maneuver in the treatment of aortoiliac aneurysms with outcomes comparable to those when IBDs extend to the main trunk of the hypogastric artery.

[Surgical anatomy of intrapelvic anastomoses of superior gluteal artery]. / Khirurgicheskaya anatomiya vnutritazovykh anastomozov verkhnei yagodichnoi arterii.

OBJECTIVE: To determine topographic variants and the number of intrapelvic anastomoses of superior gluteal artery (SGA). MATERIAL AND METHODS: There were 186 corpses of males aged 22-82 years and 109 corpses of females aged 32-93 years. All of them died from accidental causes not associated with pelvic organ diseases. Dissection, vascular injection and statistical analysis were used. RESULTS: In males, SGA forms anastomoses with other branches of internal iliac artery in 24.2% of cases on the right and in 21.0% of cases on the left. Similar collaterals in females are observed in 13.8% of cases on the right and in 15.6% of cases on the left. Mean length of intrapelvic anastomoses of a. glutea superior in males is 1.4 cm, mean diameter - 2.1 mm. Mean length of such collaterals is 2.0 cm in females, mean diameter - 2.2 mm. As a rule, anastomoses are observed in proximal and middle thirds of intrapelvic segment of SGA. Distal anastomoses are rare. Linear correlation between the diameters of a. glutea superior and intrapelvic anastomoses was not detected in females but was fixed in males. CONCLUSION: Intrapelvic anastomoses of SGA are characterized by certain pattern of discharge in men and women.

Endovascular Treatment of Claudication due to Isolated Internal Iliac Artery Occlusive Disease.

Aortoiliac occlusive disease is a common cause of lower extremity claudication. Patients are typically found to have diminished femoral pulses and abnormal noninvasive vascular studies of the lower extremities. Isolated lesions of the internal iliac arteries are much less commonly treated but can cause similar claudication symptoms in the buttocks, hips, or thighs. Occlusive disease in the internal iliac artery is more challenging to diagnose because the lower extremity pulses and vascular studies can be normal. This may falsely steer the diagnosis away from a vascular etiology. We present a case of disabling buttock claudication in a patient with normal pulses and isolated ipsilateral internal iliac artery stenosis. This was treated successfully with drug-eluting balloon angioplasty. We review the literature for similar cases of isolated internal iliac artery occlusive disease and summarize the disease characteristics and treatment modalities.

Identification of new factors associated to walking impairment in patients with vascular-type claudication.

OBJECTIVES: Mechanisms of walking limitation in arterial claudication are incompletely elucidated. We aimed to identify new variables associated to walking limitation in patients with claudication. METHODS: We retrospectively analyzed data of 1120 patients referred for transcutaneous exercise oxygen pressure recordings (TcpO2). The outcome measurement was the absolute walking time on treadmill (3.2 km/h, 10% slope). We used both: linear regression analysis and a non-linear analysis, combining support vector machines and genetic explanatory in 800 patients with the following resting variables: age, gender, body mass index, the presence of diabetes, minimal ankle to brachial index at rest, usual walking speed over 10 m (usual-pace), number of comorbid conditions, active smoking, resting heart rate, pre-test glycaemia and hemoglobin, beta-blocker use, and exercise-derived variables: minimal value of pulse oximetry, resting chest-TcpO2, decrease in chest TcpO2 during exercise, presence of buttock ischemia defined as a decrease from rest of oxygen pressure index ≤15 mmHg. We tested the models over 320 other patients. RESULTS: Independent variables associated to walking time, by decreasing importance in the models, were: age, ankle to brachial index, usual-pace; resting TcpO2, body mass index, smoking, buttock ischemia, heart rate and beta-blockers for the linear regression analysis, and were ankle to brachial index, age, body mass index, usual-pace, decrease in chest TcpO2, smoking, buttock ischemia, glycaemia, heart rate for the non-linear analysis. Testing of models over 320 new patients gave r = 0.509 for linear and 0.575 for non-linear analysis (both p < 0.05). CONCLUSION: Buttock ischemia, heart rate and usual-pace are new variables associated to walking time.

Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage.

BACKGROUND: The purpose of this article is to examine the evidence related to a unique phenomenon of purple-maroon discoloration of the buttocks found in homecare patients and to recommend a label for this phenomenon. CASES: Initially, we searched the literature to identify and retrieve any evidence related to this unique form of purple-maroon discoloration of the buttocks. No evidence was found. To illustrate the condition, we compared 4 cases of what we have labeled chronic tissue injury to 6 patients with purple-maroon discoloration of the buttocks from different causes. CONCLUSION: Chronic tissue injury is characterized by a persistent purple-maroon discoloration located on the fleshy portion of the buttocks that does not improve or deteriorate. Unlike other causes of purple discoloration such as deep tissue pressure injury, there is minimal change in the discoloration over time. Additional research is needed to further our understanding of the histopathology of this phenomenon.

Safe Gluteal Fat Graft Avoiding a Vascular or Nervous Injury: An Anatomical Study in Cadavers.

Background: Fat grafting for gluteal augmentation is one of the most popular aesthetic surgery procedures. It has an associated mortality to fat embolism of 0.2%. Objectives: The authors of this study sought to describe which technique for synthetic graft application was least likely to cause a fat embolism. Methods: Ten fresh bodies were obtained and 4 groups arranged with 5 buttocks each randomly assigned. Group 1 was infiltrated through the upper medial intergluteal sulcus (upper medial intergluteal sulcus) with an angulation of -30°, -10°, and 0°. Group 2 was infiltrated through the middle lower gluteal sulcus with an angulation of -30°, 0°, and +15°. Group 3 was infiltrated through a peritrochanteric (PT) access at the level of the femur head at 0° and +10° and in the middle of the buttock at the level of the posterior superior iliac crest at -30° toward the trochanter (lateral direction). Group 4 was infiltrated in the same manner as group 1 without -30°. A complication occurred when the graft was in contact with the vascular or nervous bundle, within the gluteus medius muscle, or both. Results: Group 1 had 3 buttocks with a complication (UMIGS -30°). Group 2 had complications in all the injection techniques. Group 3 had 5 buttocks with a complication (PT at 0°). Group 4 had no complications. Conclusions: The injection of the fat graft through the UMIGS at 0° and 10° angles, and through the middle of the buttock at the level of posterior superior iliac crest a -30° angle, reaches the surface needed for gluteal augmentation. The group 2 techniques should be avoided because they have a high risk of complication.

Idea and innovation: Secure fixation between dermis and periosteum using perforator flap to prevent recurrence of pilonidal sinus disease.

In the past decades, numerous surgical techniques and conservative treatments for pilonidal sinus disease (PSD) had been discussed and published. There is still no consensus yet of the best techniques because of high recurrence rates and prolonged wound healing. In the case of complicated discharging sinus or recurrent PSD resistant to treatment with antibiotics, we recommend radical excision followed by a regional flap, which can obliterate the dead space with well-vascularised tissue. In this article, we presented the technique of snug suture fixation between the dermis and periosteum using a superior gluteal artery perforator (SGAP) flap. The study demonstrates a few key concepts on the prevention of PSD recurrence, an off-midline, well-perfused flap that allows flattened natal cleft and obliteration of gluteal cleft and eventually showed good aesthetic results. We aim to demonstrate a reliable surgical technique for wound closure of recurrent pilonidal sinus after radical excision followed by reconstruction with an SGAP flap. The history, surgery, and images are described, and the literature is reviewed. The pitfalls of disease recurrence will be discussed in this literature. Keys to successful treatment will be elaborated. An 18-year-old female with recurrent pilonidal sinus disease over right medial gluteal region presented with sacral pain and infection. She developed progressive swelling and burst of abscess from several sinus tracts and did not respond to the treatment with antibiotics alone. After radical excision of the entire pilonidal sinus and adjacent fibrotic tissue, a deep and large defect was measured. A superior gluteal perforator flap was designed based on three perforators from the superior gluteal artery. A medial 3 cm of the SGAP flap was de-epithelised to provide soft tissue bulk to obliterate the deep cavity. Strong sutures were applied to secure the flap to the periosteum. There was no recurrence at 3 years of follow up. The patient stood the operation well and had prompt recovery.